Score Another Point for Diuretics as Most Effective Hypertension Treatment

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In 2002, the landmark Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), the largest and most racially/ethnically diverse clinical study to date comparing the effectiveness of different hypertension treatments, made counterin-tuitive history. Contrary to popular belief, the study found that traditional, less costly diuretics actually work better than newer classes of drugs—such as calcium channel blockers, ACE inhibitors and alpha-blockers—in lowering blood pressure and preventing some forms of cardiovascular disease (CVD).

Despite this dramatic finding, current medical practice continues to favor the use of these new, more expensive medications to treat high blood pressure in patients who have metabolic syndrome—a group of conditions, such as high cholesterol, diabetes and hypertension, that increase a person’s risk of developing CVD. But now, the latest results from the long-term ALLHAT study, which is sponsored by the National Heart, Lung and Blood Institute (NHLBI), strongly suggest that the most effective treatment for people who have high blood pressure as part of metabolic syndrome is—once again—diuretics.

In this new phase of the study—in which about 35% of the participants were African American—the researchers compared a diuretic (chlorthalidone) with a calcium channel blocker (amlodipine besylate), an ACE inhibitor (lisinopril) and an alpha-blocker (doxazosin mesylate). Each drug was used to start treatment and other medications could be added if necessary to control blood pressure. The findings, published in the January 28 issue of Archives of Internal Medicine, indicate that for patients with metabolic syndrome, diuretics offer greater protection against CVD, and are at least as effective in lowering blood pressure, than the newer, less affordable medicines.

“These findings are particularly important for patients with metabolic syndrome because many doctors currently prescribe [these new classes of drugs] due to their more favorable short-term effects on blood sugar and blood cholesterol levels,” says Elizabeth Nabel, MD, director of the NHLBI. “However, this new analysis shows that diuretics are better at preventing CVD and thus it does not support the selection of the newer drugs over diuretics for preventing poor health out-comes related to hypertension or for lowering high blood pressure.”

This is especially good news for African Americans, who have the highest CVD mortality rates of any racial minority group in the U.S. “In black patients with high blood pressure and metabolic syndrome, the evidence from ALLHAT overwhelmingly supports the choice of thiazide-type diuretics,” says the report’s lead author, Jackson Wright, Jr., MD, PhD, of Case Western Reserve University. For example, when compared to those taking diuretics, black ALLHAT participants receiving ACE inhibitors had poorer blood pressure control and a 24% greater risk of overall CVD, including a 19% higher risk of coronary heart disease, a 37% higher risk of stroke and a 49% greater risk of heart failure.

—compiled by Pam Chwedyk